Chapter 31-PVD and Chapter 41-DM

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Chapter 31 Assessment and Management of Patients With Vascular Disorders and Problems of Peripheral Circulation :

Chapter 31 Assessment and Management of Patients With Vascular Disorders and Problems of Peripheral Circulation

Vascular System:

Vascular System Arteries and arterioles Capillaries Veins and venules Lymphatic vessels Function of the vascular system Circulatory System

Arterial Network and Venous Network:

Slide 20-2 Arterial network begins with major arteries that branch off from aorta and branch into successively smaller arteries which subdivide and become the smallest arterial vessels, the arterioles. Arterial Network and Venous Network

Arterial Network and Venous Network:

Slide 20-2 Arterioles feed into capillary beds where oxygen and nutrients are exchanged… and deoxygenated blood begins its journey back to the heart through venules, the smallest vessels of the venous network. Venules join the smallest veins , which in turn, join larger and larger veins until reach the SVC and IVC and enter the RA Arterial Network and Venous Network

PowerPoint Presentation:

FUNCTION of Arteries : supply oxygen and essential nutrients to tissues via a pumping heart (high pressure system) Ischemia - deficient supply of oxygenated blood flow to a tissue caused obstruction of a blood vessel; Complete blockage = death of tissue .

PowerPoint Presentation:

Artery walls Contain elastic fibers...stretch with systole and recoil with diastole Contain muscle fibers… control amount of blood delivered to tissues by contracting or dilating; diameter change controls flow rate

Peripheral Blood Flow:

Peripheral Blood Flow Movement of fluid across the capillary wall; hydrostatic and osmotic force

Peripheral Blood Flow:

Peripheral Blood Flow Hemodynamic resistance Blood viscosity Vessel diameter

Peripheral Blood Flow:

Peripheral Blood Flow Regulation of peripheral vascular resistance CNS

FACTORS affecting Arterial Circulation & BP:

FACTORS affecting Arterial Circulation & BP Sympathetic and parasympathetic Nervous system Kidneys Temperature Dietary Factors Race, Gender, Age, Weight, Time of day, Position, Exercise, Emotional state

BP represents the force that blood exerts against the artery walls as it is pumped from the heart. Which of the following describes Systole: :

BP represents the force that blood exerts against the artery walls as it is pumped from the heart. Which of the following describes Systole: is considered a direct measurement of the blood pressure in the right atrium and vena cava. the highest pressure exerted against the arterial walls at the peak of ventricular contraction the lowest exerted against the arterial walls at the peak of ventricular relaxation is the highest pressure exerted against the arterial walls during expiration

BP represents the force that blood exerts against the artery walls as it is pumped from the heart. Which of the following describes Systole: :

BP represents the force that blood exerts against the artery walls as it is pumped from the heart. Which of the following describes Systole: is considered a direct measurement of the blood pressure in the right atrium and vena cava. the highest pressure exerted against the arterial walls at the peak of ventricular contraction the lowest exerted against the arterial walls at the peak of ventricular relaxation is the highest pressure exerted against the arterial walls during expiration

FACTORS affecting Arterial Circulation & BP:

FACTORS affecting Arterial Circulation & BP Sympathetic and Parasympathetic Nervous system Regulate BP Sympathetic effect on peripheral vascular resistance (PVR)  vasoconstriction  of arterioles,  BP Parasympathetic effect on (PVR)  vasodilation of arteriole,  BP

FACTORS affecting Arterial Circulation & BP:

PARASYMPATHETIC AND SYMPATHETIC Kidneys maintain BP by excreting or conserving sodium & water FACTORS affecting Arterial Circulation & BP increased blood flow Fluid Volume/BP Na & H2O Excreted (urine)

FACTORS affecting Arterial Circulation & BP:

Parasympathetic and Sympathetic KIDNEYS TEMPERATURE Cold = vasoconstriction Warmth = vasodilation FACTORS affecting Arterial Circulation & BP

FACTORS affecting Arterial Circulation & BP:

Parasympathetic and Sympathetic KIDNEYS TEMPERATURE Dietary Factors intake of salt saturated fats and cholesterol Elevate BP by affecting blood volume (Na) and vessel diameter (cholesterol) FACTORS affecting Arterial Circulation & BP

FACTORS affecting Arterial Circulation & BP:

Parasympathetic and Sympathetic KIDNEYS TEMPERATURE Dietary Factors Race (African American, not blacks in Africa ) Gender (males and post menopausal females) Age (increases with age) Weight (increases with weight) Time of day (increases late afternoon/evening) Position (arm at level of heart and postural hypotension) Exercise (increases then returns to normal with in 5”) Emotional state (increases with anger, excitement, fear) FACTORS affecting Arterial Circulation & BP

Arterial circulation and blood pressure are affected by the Sympathetic and parasympathetic nervous system. When the sympathetic nervous system is activated which of the following occur: :

Arterial circulation and blood pressure are affected by the Sympathetic and parasympathetic nervous system. When the sympathetic nervous system is activated which of the following occur: Increased BP, increased HR, and vasoconstriction Decreased BP, decreased HR and vasodilation Increased BP, bradycardia and decreased urinary output None of the above

Arterial circulation and blood pressure are affected by the Sympathetic and parasympathetic nervous system. When the sympathetic nervous system is activated which of the following occur: :

Arterial circulation and blood pressure are affected by the Sympathetic and parasympathetic nervous system. When the sympathetic nervous system is activated which of the following occur: Increased BP, increased HR, and vasoconstriction Decreased BP, decreased HR and vasodilation Increased BP, bradycardia and decreased urinary output None of the above

Atherosclerosis:

Atherosclerosis

Arteriosclerosis VS Atherosclerosis:

Arteriosclerosis VS Atherosclerosis Normal changes that occur with aging (ARTERIOSCEROLSIS) Abnormal disorder of the vascular system (ATHEROSCEROSIS) Was: flexible, strong, elastic Was : flexible, strong, elastic Time/age: walls thicken become stiff and hard Damage to Artery walls Preventable causes: smoking, high BP, Diet, High cholesterol Family Hx ; aneurysm <50y/o EFFECT : sometimes restricts blood flow to organs/tissues EFFECT: Build up of plaques on artery walls restrict blood flow, forms clots

PowerPoint Presentation:

Cross section of coronary artery with atherosclerotic plaque Arteriosclerosis Narrowed artery less elastic Atherosclerosis animation http://www.nlm.nih.gov/medlineplus/ency/anatomyvideos/000006.htm

Progression of Atherosclerosis:

Progression of Atherosclerosis

Risk Factors:

Risk Factors Hardening of the arteries (Arteriosclerosis) occurs over time from simply getting older Fatty deposits (plaques) made of cholesterol line inner artery walls (Atherosclerosis) occur from: High blood pressure High cholesterol Diabetes Obesity Smoking A family history of aneurysm or early (< age 50)heart disease

Symptoms to assess Atherosclerosis:

Symptoms to assess Atherosclerosis usually doesn't have any symptoms. None until …artery can't supply adequate blood to your organs and tissues.

Symptoms to assess Atherosclerosis:

Symptoms to assess Atherosclerosis Sometimes a blood clot completely blocks blood flow, or even breaks off causing a heart attack or stroke. Symptoms depend on which arteries are affected.

Symptoms to assess Atherosclerosis:

Symptoms to assess Atherosclerosis If you have atherosclerosis in your heart arteries, you may have symptoms similar to those of a heart attack, such as chest pain (angina). plaque Decreased Blood flow (O2 ,etc)

Symptoms to assess Atherosclerosis:

Symptoms to assess Atherosclerosis If you have atherosclerosis in the arteries(carotid)leading to your brain, Signs and Symptoms of Stroke (transient ischemic attack :TIA) Facial droop (unilaterally) Arms/legs sudden numbness weakness Slurred speech

Symptoms to assess Atherosclerosis:

Symptoms to assess Atherosclerosis If you have atherosclerosis in the arteries in your arms and legs S/Sx peripheral artery disease, Color change in extremity leg pain when walking (intermittent claudication) . Can lead to amputation Diminished pulses

Symptoms to assess Atherosclerosis:

Symptoms to assess Atherosclerosis May cause to erectile dysfunction

Pulses are graded for force (amplitude):

Pulses are graded for force (amplitude) Describe all pulses as : Full/bounding (increased) (3+), Normal (2+), Weak (diminished) (1+), or Absent (0)

PowerPoint Presentation:

ARTERIES IN THE ARM Brachial - runs in the biceps-triceps furrow; palpate in the antecubital fossa ; bifurcates into ulnar and radial Ulnar - lies just medial to ulna; difficult to palpate Radial - lies just medial to radius; palpable

PowerPoint Presentation:

ARTERIES IN THE LEG Femoral- under inguinal ligament, down thigh Popliteal - behind knee and divides into  Dorsalis pedis - dorsum of foot Posterior tibial - Behind medial malleolus

Continuous-wave Doppler ultrasound detects blood flow, combined with computation of ankle or arm pressures; this diagnostic technique helps characterize the nature of peripheral vascular disease. :

Continuous-wave Doppler ultrasound detects blood flow, combined with computation of ankle or arm pressures; this diagnostic technique helps characterize the nature of peripheral vascular disease.

How to perform ankle-brachial index (ABI):

How to perform ankle-brachial index (ABI) Highest (systolic) Highest (systolic) ABI = Ankle Pressure ÷ Brachial Pressure ABI 1.0 = no arterial insufficiency ABI mild insufficiency 0.95-0.50 = (intermittent claudication) ABI <0.5 = pain at rest ABI <0.25= necrosis or tissue loss http://www.youtube.com/watch?v=CD3jIZap9LM&feature=related

Question:

Question Is the following statement True or False? Intermittent claudication is caused by the inability of the venous system to provide adequate blood flow to the tissues in the face of increased demands for nutrients and oxygen during exercise.

Answer:

Answer False Intermittent claudication is caused by the inability of the arterial system, not the venous system, to provide adequate blood flow to the tissues in the face of increased demands for nutrients and oxygen during exercise.

Question:

Question What is a non-modifiable risk factor for atherosclerosis and PVD ? Hypertension Diabetes Obesity Familial predisposition/genetics

Answer:

Answer D Hypertension, diabetes, and obesity are modifiable risk factors for atherosclerosis and PVD. Familial predisposition/genetics is a nonmodifiable risk factor.

Medical Management:

Medical Management Prevention Exercise program Medications Pentoxifylline (Trental) and cilostazol (Pletal) Use of antiplatelet agents Surgical management

Nursing Process: The Care of the Patient with Peripheral Arterial Insufficiency—Assessment:

Nursing Process: The Care of the Patient with Peripheral Arterial Insufficiency—Assessment Health history Medications Risk factors Signs and symptoms of arterial insufficiency Claudication and rest pain Color changes Weak or absent pulses Skin changes and skin breakdown

Nursing Process: The Care of the Patient with Peripheral Arterial Insufficiency—Diagnoses:

Nursing Process: The Care of the Patient with Peripheral Arterial Insufficiency—Diagnoses Altered peripheral tissue perfusion Chronic pain Risk for impaired skin integrity Knowledge deficient

Nursing Process: The Care of the Patient with Peripheral Arterial Insufficiency—Planning:

Nursing Process: The Care of the Patient with Peripheral Arterial Insufficiency—Planning increased arterial blood supply promotion of vasodilatation prevention of vascular compression relief of pain attainment or maintenance of tissue integrity adherence to self-care program

Improving Peripheral Arterial Circulation:

Improving Peripheral Arterial Circulation Exercises and activities: walking, graded isometric exercises. Note: consult primary health care provider before prescribing an exercise routine Positioning strategies Temperature; effects of heat and cold Stop smoking Stress reduction

Maintaining Tissue Integrity:

Maintaining Tissue Integrity Protection of extremities and avoidance of trauma Regular inspection of extremities with referral for treatment and follow-up for any evidence of infection or inflammation Good nutrition, low-fat diet Weight reduction as necessary

Promoting Hygiene: foot care:

Promoting Hygiene: foot care Wash and Dry Feet Daily Use mild soaps. Use warm water. Pat skin dry; do not rub. Thoroughly dry feet. After washing, use lotion on feet to prevent cracking. Do not put lotion between toes.

Promoting Hygiene: foot care:

Promoting Hygiene: foot care Care of Toenails Cut toenails after bathing, when they are soft. Cut toenails straight across and smooth with a nail file. Avoid cutting into the corners of toes. Diabetic Client may need an order for a podiatrist to cut toenails.

Promoting Hygiene: foot care Care for Clients with Diabetes:

Promoting Hygiene: foot care Care for Clients with Diabetes Diabetes is a chronic (long-term) illness that occurs when your body does not make enough insulin. Insulin is a hormone that allows your cells to use the sugar in your blood for energy. Chronic high blood sugar levels can damage the blood vessels and nerves in your legs and feet.

Factors affecting foot care of a Diabetic Client:

Factors affecting foot care of a Diabetic Client Neuropathy: Neuropathy is nerve damage. Nerves carry information needed for you to feel touch, pressure, pain, and temperature. Peripheral vascular disease (PVD) occurs when your blood vessels become narrow or blocked. PVD causes decreased blood flow to your feet. Blood contains oxygen and cells that are needed for your body to heal when it is injured. You may heal slowly and you may have an increased risk of infection Poor vision: Problems with your vision may make it hard for you to see problems with your feet.

Foot Care of a Diabetic Client:

Foot Care of a Diabetic Client Assess for ability to feel sensation in feet (pain, temperature, pressure) Assess capillary refill, color and temperature of feet Palpate the pedal pulses and compare bilaterally Inspect for lesions, callus, corns, ingrown toe nails fungal infections Foot care can be delegated EXCEPT for patients with diabetes or circulatory compromise.

Foot Care of a Diabetic Client:

Foot Care of a Diabetic Client Wash and dry feet daily Cut toe nails straight across Inspect feet daily for common problems (p233) Teach client: Never go barefoot Always wear socks

PowerPoint Presentation:

A nurse is preparing a teaching plan for a client with diabetes mellitus regarding proper foot care. Which instruction is included in the plan? 1. soak feet in hot water 2. avoid using a mild soap on the feet 3. apply a moisturizing lotion to dry feet but not between the toes 4. always have a podiatrist cut your toe nails; never cut them yourself

PowerPoint Presentation:

A nurse is preparing a teaching plan for a client with diabetes mellitus regarding proper foot care. Which instruction is included in the plan? 1. soak feet in hot water 2. avoid using a mild soap on the feet 3. apply a moisturizing lotion to dry feet but not between the toes 4. always have a podiatrist cut your toenails;never cut them yourself The client is instructed to use a moisturizing lotion on the feet and to avoid applying the lotion between the toes. The client should be instructed not to soak the feet and should avoid hot water to prevent burns. The client may cut the toenails straight across and even with the toe itself and would consult a podiatrist if the toenails were thick or hard to cut or if vision were poor. The client should be instructed to wash the feet daily with a mild soap.

Buerger’s Disease—Thromboangitis Obliterans:

Buerger’s Disease—Thromboangitis Obliterans Recurring inflammatory process (and clotting) of the small and intermediate vessels of (usually) the lower extremities; probably an autoimmune disorder. Most often occurs in men ages 20 to 35. Risk or aggravating factor: tobacco. Progressive occlusion of vessels results in pain, ischemic changes, ulcerations, and gangrene.

Raynaud's Disease:

Raynaud's Disease Intermittent arterial vasoocclusion, usually of the fingertips or toes. Raynaud's phenomenon is associated with other underlying disease such as scleroderma . Manifestations: sudden vasoconstriction results in color changes, numbness, tingling, and burning pain. Episodes are usually brought on by a trigger such as cold or stress. Occurs most frequently in young women. Protect from cold/other triggers. Avoid injury to hands/fingers.

PowerPoint Presentation:

*scleroderma Scleroderma is a connective tissue disease that involves changes in the skin, blood vessels, muscles, and internal organs. It is a type of autoimmune disorder, a condition that occurs when the immune system mistakenly attacks and destroys healthy body tissue.

Question:

Question Is the following statement True or False? Arteries are thick-wall structures that carry blood from the heart to the tissues.

Answer:

Answer True Arteries are thick-wall structures that carry blood from the heart to the tissues.

Other Disorders:

Other Disorders Aortoiliac disease Aneurysms Thoracic aortic aneurysm Abdominal aortic aneurysm Aortic dissection

Other Disorders:

Other Disorders Aortoiliac occlusive disease occurs when your iliac arteries become narrowed or blocked.

Aortoiliac Endarterectomy Figure 31-10:

Aortoiliac Endarterectomy Figure 31-10 Removal of plaque

Aneurysm:

Aneurysm balloon-like bulge in an artery An aneurysm can grow large and rupture causing dangerous bleeding inside the body Most aneurysms occur in the aorta, The aorta goes through the chest and abdomen. Both rupture and dissection often are fatal.

Assessment AAA:

Assessment AAA Palpate Aorta Laterally Use thumb and pointer finger (pincer-type) to palpate width of aortic pulsation Normal is 2.5-4cm Auscultate for bruits using the bell of your stethoscope

Characteristics of Arterial Aneurysms:

Characteristics of Arterial Aneurysms Once an aneurysm reaches 5 cm in diameter, it is usually considered necessary to treat to prevent rupture. Below 5cm, the risk of the aneurysm rupturing is lower than the risk of conventional surgery in patients with normal surgical risks. The goal of therapy for aneurysms is to prevent them from rupturing. Once an abdominal aortic aneurysm has ruptured, the chances of survival are low, with 80 to 90 percent of all ruptured aneurysms resulting in death. These deaths can be avoided if an aneurysm is detected and treated before it ruptures.

Repair of Abdominal Aortic Aneurysm:

Repair of Abdominal Aortic Aneurysm Refer to fig. 31-13 Surgical Repair - clamp off the aorta, cuts open the aneurysm and sews in a graft to act as a bridge for the blood flow. The blood flow then goes through the plastic graft and no longer allows the direct pulsation pressure of the blood to further expand the weak aorta wall.

Question:

Question What is an aneurysm? Junction of two vessels. Narrowing of constriction of a vessel. A localized sac or dilation of an artery formed at a weak point in the vessel wall. Sound produced by turbulent blood flow through an irregular, tortuous, stenotic, or dilated vessel.

Answer:

Answer C An aneurysm is a localized sac or dilation of an artery formed at a weak point in the vessel wall. Anastomosis is a junction of two vessels. Stenosis is narrowing of constriction of a vessel. Bruit is the sound produced by turbulent blood flow through an irregular, tortuous, stenotic, or dilated vessel.

PowerPoint Presentation:

Atherosclerosis is a normal age related change in the arterial walls that leads to thickening and stiffening of the artery. True or False

PowerPoint Presentation:

Atherosclerosis is a normal age related change in the arterial walls that leads to thickening and stiffening of the artery. False

:

Chapter 20 FUNCTION : Drain de-oxygenated blood and waste products from the tissue and return it to the heart Pressure is lower in veins than in arteries therefore: -vein walls are thinner than artery walls; -veins have larger diameters and -veins hold more blood when volume increases - there are many more veins than arteries VEINS

:

Slide 20-3 Chapter 20 Do not have a pump to generate blood flow; the venous system is a low pressure system …because veins have no mechanism to generate their blood flow  VEINS

VEINS NEED A MECHANISM TO KEEP BLOOD MOVING :

VEINS NEED A MECHANISM TO KEEP BLOOD MOVING Pressure gradient Muscle contraction Valves

PowerPoint Presentation:

VEINS NEED A MECHANISM TO KEEP BLOOD MOVING Pressure gradient caused by breathing (inspiration thoracic pressure  & abd . pressure  Contracting skeletal muscles that milk blood proximally back toward heart Intraluminal valves which ensure one-way flow (valves open toward heart and close when filled to prevent backflow)

Veins in the arm:

Veins in the arm Deep run along arteries (Subclavian) Superficial responsible for most of venous return

PowerPoint Presentation:

Veins in the leg Deep veins-; Femoral & Popliteal conduct most of venous return from legs 2. Superficial veins: Great/small saphenous (can live without) 3. Perforators (connecting veins that join the 2 sets; have one-way valves that route blood from the superficial into the deep veins)

Venous Thromboembolism:

Venous Thromboembolism Risk factors (Chart 31-7 pg 875) Endothelial damage Trauma/surgery Catheters/pacer wires Venous stasis BR Obesity Varicosity age Altered Coagulation Cancer, oral contraceptives Pregnancy, Polycythemia Protein Cor S deficiency, Elevated Factors (VIII) Virchow’s Triad

Venous Thromboembolism:

Venous Thromboembolism Pathophysiology Aggregated of platelets attached to the vein wall that have a tail-like appendage of WBC, RBC and fibrin. Tails can break off and occlude Pulmonary blood vessels (break off from pressure of movement, insertion of catheters)

Blood flow and function of valves in veins. Note impaired blood return due to incompetent valve.:

Blood flow and function of valves in veins. Note impaired blood return due to incompetent valve.

Lower Extremity Assessment:

Lower Extremity Assessment Inspect and Palpate the legs while patient is supine, noting swelling, thickened skin, cyanosis, stasis dermatitis ( brown pigment, erythema, scaling), hair distribution, ulcers Normal: Venous pattern on both legs should be symmetric and no edema, cyanosis, lesions Asymmetry of > 1 cm is abnormal; Possible Deep Vein Thrombosis (DVT) or lymphedema)

Homan’s sign http://www.youtube.com/watch?v=RYEzDRJhnf4&feature=related :

Homan’s sign http://www.youtube.com/watch?v=RYEzDRJhnf4&feature=related Homan ’ s sign = dorsiflex foot toward tibia; positive sign if pain) Calf muscle (normal is no tenderness compressing gastronemius);

Pretibial Edema depress skin over tibia or medial malleolus for 5 seconds :

Pretibial Edema depress skin over tibia or medial malleolus for 5 seconds 1+ no visible change; slight indentation (-2mm depression) 2+ no marked change in leg; pitting disappears in 10-15 sec (-4 mm depression) 3+ leg visibly swollen; may last > 1 minute(-6 mm depression) 4+ leg very swollen/distorted; lasts 2-5 min(-8mm depression)

Preventive Measures:

Preventive Measures Elastic hose Pneumatic compression devices Subcutaneous heparin or LMWH, warfarin (Coumadin) for extended therapy Positioning: periodic elevation of lower extremities Exercises: active and passive limb exercises, and deep breathing exercises Early ambulation Avoid sitting/standing for prolonged periods; walk 10 minutes every 1-2 hours.

PowerPoint Presentation:

Anticoagulants

PowerPoint Presentation:

Oral anti-coagulants warfarin (Coumadin)

Contraindications to Anticoagulant therapy:

Contraindications to Anticoagulant therapy Bleeding GI GU Aneurysms Severe trauma ETOH Impending Surgery of EYE, Spinal Cord, brain Hepatic/Renal disease CVA (hemorrhagic) Infections Open ulcerative wounds Occupations with hazards Recent child birth

Complications of Venous Thrombosis:

Complications of Venous Thrombosis

PowerPoint Presentation:

Valvular Destruction Chronic venous insufficiency Varicosities Venous Ulcers Venous obstruction Fluid stasis Venous gangrene Edema

Nursing Process: The Care of the Patient with Leg Ulcers—Assessment:

Nursing Process: The Care of the Patient with Leg Ulcers—Assessment History of the condition Treatment depends upon the type of ulcer (arterial or venous) Assess for presence of infection Assess nutrition

Arterial Ulcer, Gangrene Due to Arterial Insufficiency, and Ulcer Due to Venous Stasis:

Arterial Ulcer, Gangrene Due to Arterial Insufficiency, and Ulcer Due to Venous Stasis

PowerPoint Presentation:

Venous Ulcers Arterial Ulcers

PowerPoint Presentation:

http://www.studystack.com/flashcard-224970 http://www.studystack.com/matching-224970 http://www.studystack.com/matching-697702

Medical Management:

Medical Management Anti-infective therapy is dependent upon infecting agent (if infected) Oral antibiotics are usually prescribed. Compression therapy (not for arterial) Debridement of wound Dressings

PowerPoint Presentation:

Generally ischemic (arterial) ulcers appear on distal feet and toes, sites of diminished vascular perfusion. Ischemic symptoms include intermittent claudication and supine nocturnal pain, relieved by foot dangling. Compression therapy is usually contraindicated in the treatment of arterial ulcers because it exacerbates ischemia. However, one type of compression device has been developed which incorporates a heart monitor so that pneumatic compression can be timed to the end-diastolic portion of the heart rhythm to improve arterial flow and heal ischemic ulcers (e.g., The Circulator Boot).

Nursing Process: The Care of the Patient with Leg Ulcers- Diagnoses:

Nursing Process: The Care of the Patient with Leg Ulcers- Diagnoses Impaired skin integrity Impaired physical mobility Imbalanced nutrition

Collaborative Problems/Potential Complications:

Collaborative Problems/Potential Complications Infection Gangrene

Nursing Process: The Care of the Patient with Leg Ulcers—Planning:

Nursing Process: The Care of the Patient with Leg Ulcers—Planning Major goals include restoration of skin integrity, improved physical mobility, adequate nutrition, absence of complications.

Mobility:

Mobility With leg ulcers, activity is usually initially restricted to promote healing Gradual progression of activity Activity to promote blood flow; encourage patient to move about in bed and exercise upper extremities Diversional activities (increase ability to participate) Pain medication prior to activities

Other Interventions:

Other Interventions Skin integrity Skin care/hygiene and wound care Positioning of legs to promote circulation Avoidance of trauma Nutrition Measures to ensure adequate nutrition Adequate protein, vitamin C and A, iron, and zinc are especially important for wound healing Include cultural considerations and patient teaching in the dietary plan

Structure and Function: LYMPHATIC SYSTEM :

Structure and Function: LYMPHATIC SYSTEM A separate vessel system from arteries and veins FUNCTION with vascular system : Retrieves excess fluid from tissue spaces returns it to bloodstream; more fluid leaves capillaries than veins can absorb…so lymph retrieves that excess fluid if fluid is not retrieved, it builds up in interstitial spaces and produces edema

Lymphatic system:

Lymphatic system

LYMPHATIC SYSTEM :

LYMPH NODES : Small oval clumps of lymphatic tissue found in chains along the vessels; Normally, not palpable Superficial nodes, sites accessible to inspection/ palpation CERVICAL NODES drain the head and neck AXILLARY NODES drain breast and upper arm EPITROCHLEAR NODES drain hand and lower arm (antecubital fossa); INGUINAL NODES in groin and drain lower extremities, external genitalia, and anterior abdominal wall LYMPHATIC SYSTEM

LYMPHATIC SYSTEM Functions :

Slide 20-4 Chapter 20 LYMPHATIC SYSTEM Functions 1. Conserve fluid and plasma proteins that leak out of capillaries 2. Form a major part of the immune system 3. Absorb lipids from the intestinal tract

PowerPoint Presentation:

Right lymphatic duct RIGHT Subclavian vein; Drains right side head & neck, arm, thorax, lung & pleura, heart, upper section of liver Thoracic duct LEFT Subclavian vein ; Drains the rest of the body

LYMPHATIC SYSTEM :

LYMPHATIC SYSTEM Lymph flow is propelled by (1) contracting skeletal muscles , (2) by pressure changes 2 o to breathing, and (3) by contraction of the vessel walls themselves

The Aging Adult’s Lymph System:

The Aging Adult ’ s Lymph System Loss of lymphatic tissue  fewer lymph nodes ;  size of remaining ones

Which of the following is responsible for generating blood flow in the veins?:

Which of the following is responsible for generating blood flow in the veins ? Heart contractions and lymph pressure Thoracic pressure from breathing and skeletal muscle contraction Intraluminal valves in the arteries and heart contractions Just the heart contracting

Which of the following is responsible for generating blood flow in the veins :

Which of the following is responsible for generating blood flow in the veins Heart contractions and lymph pressure Thoracic pressure from breathing and sketetal muscle contraction Intraluminal valves in the arteries and heart contractions Just the heart contracting

All of the following are true about veins EXCEPT: :

All of the following are true about veins EXCEPT: Pressure is lower in veins than in arteries there are less veins than arteries vein walls are thinner than artery walls veins have larger diameters than arteries Veins carry deoxygenated blood

All of the following are true about veins EXCEPT: :

All of the following are true about veins EXCEPT: Pressure is lower in veins than in arteries there are less veins than arteries vein walls are thinner than artery walls veins have larger diameters than arteries Veins carry deoxygenated blood

The nurse is assessing the peripheral vascular status of a 45 year old female and measures the calf circumference of the right calf = 13.5cm and the Left calf circumference= 14.0 cm. The nurse should: :

The nurse is assessing the peripheral vascular status of a 45 year old female and measures the calf circumference of the right calf = 13.5cm and the Left calf circumference= 14.0 cm. The nurse should: Do nothing this finding is with in normal limits Call the doctor this finding indicates a possible blood clot Check the capillary refill to determine if blood flow is impaired Elevate the leg and reassess in one hour

The nurse is assessing the peripheral vascular status of a 45 year old female and measures the calf circumference of the right calf = 13.5cm and the Left calf circumference= 14.0 cm. The nurse should: :

The nurse is assessing the peripheral vascular status of a 45 year old female and measures the calf circumference of the right calf = 13.5cm and the Left calf circumference= 14.0 cm. The nurse should: Do nothing this finding is with in normal limits Call the doctor this finding indicates a possible blood clot Check the capillary refill to determine if blood flow is impaired Elevate the leg and reassess in one hour

Cellulitus and Lymphatic Disorders:

Cellulitus and Lymphatic Disorders Cellulitus: infection and swelling of skin tissues Lymphangitis: inflammation/infection of the lymphatic channels Lymphadenitis: inflammation/infection of the lymph nodes Lymphedema: tissue swelling related to obstruction of lymphatic flow Primary: congenital Secondary: acquired obstruction

Nursing Management of Cellulitis:

Nursing Management of Cellulitis Elevate extremity Apply warm moist packs every 2-4 hours PVD/Diabetes, meticulous skin and foot care Antibiotics as prescribed

Medical Management of Lymph disorders:

Medical Management of Lymph disorders Active & Passive exercises External compression Manual drainage Lasix /Antibiotics Possible surgery

NCLEX:

NCLEX A patient comes to the clinic and c/o pain his foot after stepping on a nail a couple of days ago. The patient has a red streak up his leg. What would the nurse suspect? Cellulitis Minor superficial skin irritation Elephantiasis Lymphangitis

NCLEX:

NCLEX A patient comes to the clinic and c/o pain his foot after stepping on a nail a couple of days ago. The patient has a red streak up his leg. What would the nurse suspect? Cellulitis Minor superficial skin irritation Elephantiasis Lymphangitis

Chapter 41 Assessment and Management of Patients With Diabetes Mellitus:

Chapter 41 Assessment and Management of Patients With Diabetes Mellitus

Learning Objectives :

Learning Objectives Differentiate between hyperglycemia with diabetic ketoacidosis and hyperosmolar nonketotic syndrome. Describe management strategies for a person with diabetes to use during “sick days.” Describe the major macrovascular , microvascular , and neuropathic complications of diabetes and the self-care behaviors that are important in their prevention. Explain the dietary modifications used for management of people with diabetes Describe the relationships among diet, exercise, and medication ( ie , insulin or oral antidiabetic agents) for people with diabetes.

Diabetes Mellitus :

Diabetes Mellitus A group of diseases characterized by hyperglycemia due to defects in insulin secretion, insulin action, or both Affects nearly 21 million people in the United States Almost 1/3 of cases are undiagnosed Prevalence is increasing Minority populations and the elderly are disproportionately affected

PowerPoint Presentation:

Concepts in Action- Diabetes

Classifications of Diabetes:

Classifications of Diabetes Type 1 diabetes Type 2 diabetes Gestational diabetes Diabetes Insipidus (which has nothing to do with blood sugar)

Type 1 Diabetes:

Absence of insulin production; client is dependant on insulin to prevent ketoacidosis Onset is acute and usually in childhood (AKA juvenile diabetes or IDDM) Type 1 Diabetes

Type 2 Diabetes:

Decreased sensitivity to insulin (insulin resistance) and inadequate insulin production 90–95% of person with diabetes More common in persons over age 40 and in the obese Slow, progressive glucose intolerance, Treated w/diet and exercise, oral hypoglycemic agents (sometime insulin) Type 2 Diabetes

Functions of Insulin:

Functions of Insulin Transports and metabolizes glucose for energy Stimulates storage of glucose in the liver and muscle as glycogen Signals the liver to stop the release of glucose Enhances the storage of dietary fat in adipose tissue Accelerates transport of amino acids into cells Inhibits the breakdown of stored glucose, protein, and fat

Pathogenesis of Type 2 Diabetes:

Pathogenesis of Type 2 Diabetes

Pathophysiology DM:

Pathophysiology DM Insulin increases during eating to regulate carbohydrate metabolism Insulin is secreted by beta cells in islets of langerhans (pancreas) If carbohydrates are not available (due to insulin problem) break down of fats ketone bodies

Pathophysiology DM:

Pathophysiology DM When fats are used as a primary energy source, the serum lipid levels rise development of atherosclerosis

Question:

Question Is the following statement True or False? Type 1 diabetes mellitus is treated initially with diet and exercise.

Answer:

Answer False Type 2 diabetes mellitus, NOT type 1 diabetes mellitus, is treated initially with diet and exercise.

Risk Factors:

Risk Factors not inherited but a genetic predisposition combined with immunologic environmental (viral) factors family history of diabetes, obesity, race/ethnicity, age greater than 45 years, hypertension ≥ 140/90, HDL ≤ 35 and/or triglycerides ≥ 250, history of gestational diabetes or babies over 9 pounds TYPE 1 Type 2

Clinicial Manifestations:

Clinicial Manifestations

PowerPoint Presentation:

*weakness, vision changes, tingling or numbness in hands or feet, dry skin, skin lesions

PowerPoint Presentation:

*insulin available but can’t be used

Gestational Diabetes:

Gestational Diabetes Develops during pregnancy usually detected at 24-28 weeks. Glucose tolerance usually returns to normal after delivery Increased risk for type 2 diabetes later in life

Pathophysiology for symptoms:

Pathophysiology for symptoms Polyuria: serum osmolarity circulating volume water not reabsorbed in renal tubules increasing urine output . Polydipsia: fluid loss= increased thirst from dehydration Polyphasia: Tissue break down causes hunger Weightloss (typeI): glucose is not available to cells and begins to break down fat and protein

Diagnostic Findings:

Diagnostic Findings Fasting blood glucose 126 mg/ dL or more Random glucose exceeding 200 mg/ dL Glucose tolerance test: 2 hours levels >200mg/ dL Glycosuria –body can’t use sugar so it is excreted in the urine (if + test for ketones ) Glycosylated hemoglobin (HbA1c) <7% demonstrates good control of Blood Sugar but not used for initial diagnosis

Treatment goal is to normalize blood glucose levels:

Treatment goal is to normalize blood glucose levels Intensive control dramatically decreases complications of diabetes, eye, kidney, nerve, genitourinary, peripheral vascular, and foot complications

Dietary Management—Goals:

Dietary Management—Goals Provide optimal nutrition; all essential food constituents Meet energy needs Achieve and maintain a reasonable weight Prevent wide fluctuations of blood glucose levels Decrease serum lipids, if elevated http://www.diabetes.org/food-and-fitness/food/what-can-i-eat/

Diabetic Diet:

Diabetic Diet 50-60% carbohydrates (low glycemic index foods and increase dietary fiber) 20-30% fat (reduced and trans fat foods) 10-20% protein (significantly lower than the normal adult due to the stress that moderate to high protein places on the kidneys)

Role of the Nurse:

Role of the Nurse Be knowledgeable about dietary management http://www.diabetes.org/food-and-fitness/food/planning-meals/create-your-plate/ Communicate important information to the dietician or other management specialists Reinforce patient understanding Support dietary and lifestyle changes

Meal Planning:

Meal Planning Consider food preferences, lifestyle, usual eating times, and cultural/ethnic background Review diet history and need for weight loss, gain, or maintenance (reduce diet intake by 500-1000 calorie per day for 1-2 lbs weight loss per week) Caloric requirements and calorie distribution throughout the day http://www.diabetes.org/mfa-recipes/meal-plans/

Glycemic Index:

Glycemic Index Describes how much a food increases blood glucose Combine starchy food with protein and fat containing food slows absorption, and glycemic response Raw or whole foods tend to have lower response than cooked, chopped, or pureed foods Eat whole fruits rather than juices; decreases glycemic response due to fiber-slowing absorption Adding food with sugars may produce lower response if eaten with foods that are more slowly absorbed http://www.diabetes.org/food-and-fitness/food/what-can-i-eat/diabetes-superfoods.html

Other Dietary Concerns:

Other Dietary Concerns Alcohol-don’t need to avoid, but large amounts can convert to fat increasing the risk for DKA It can increase likelihood of hypoglycemia if taken on empty stomach, and impair ability to recognize the signs of hypoglycemia One per day for women/2 per day for men

Other Dietary Concerns:

Other Dietary Concerns Nutritive and nonnutritive sweeteners Nutritive sweeteners contain calories and include fructose (fruit sugar)but cause less elevation in blood sugar than table sugar (sucrose) Sorbitol –contained in “sugar free foods” Can cause diarrhea Non-Nutritive sweeteners contain little to no calories and produce no elevation in blood sugar. Saccharin, aspartaime (NutraSweet), sucralose ( Splenda )

Other Dietary Concerns:

Other Dietary Concerns Reading labels http://www.diabetes.org/food-and-fitness/food/what-can-i-eat/taking-a-closer-look-at-labels.html

Exercise:

Exercise Lowers blood sugar Aids in weight loss Lowers cardiovascular risk

Exercise Precautions:

Exercise Precautions Do not exercise if BS > 240 mg/ dL or ketones in urine Resume exercise when urine ketone test is negative Insulin normally decreases with exercise; patients taking insulin should eat a 15g carbohydrate snack before moderate exercise to prevent hypoglycemia Hypoglycemia may occur many hours after exercise If exercising to control or reduce weight, insulin must be adjusted Need to monitor blood glucose levels before during and after when exercising for prolonged periods

Exercise Recommendations:

Exercise Recommendations Encourage regular daily exercise Gradual, slow increase in exercise period is encouraged Modify exercise regimen to patient needs and presence of diabetic complications or potential cardiovascular problems Exercise stress test for patients older than age 30 who have 2 or more risk factors is recommended

Concepts in Action- Hormonal Control of Blood Glucose :

Concepts in Action- Hormonal Control of Blood Glucose DVD-ROM

Pharmacological intervention:

Pharmacological intervention Oral Antidiabetic Agents (pg1215) Effective for type 2 diabetes not responsive to diet and exercise alone(not a replacement for) Stimulate beta cells to secrete more insulin, enhance the body utilization of available insulin

Oral Antidiabetic Agents :

Oral Antidiabetic Agents General implications Dose should be decreased for older adults Use with caution in clients with renal or hepatic failure All oral hypoglycemic agents are contraindicated for pregnant women Carefully observed for hypo/hyperglycemia Medication should be taken in the morning Long-term therapy may result in ineffectiveness

Types of Oral Antidiabetic Agents:

Types of Oral Antidiabetic Agents First generation Sulfonylureas Diabenise Orinace Second Generation Sulfonylureass Glipizide (glucotrol) Glyburide (micronase) Glimepiride (Amaryl) Biguanides (inhibit liver production of glucose) Metaformin (glucophage) Metaformin with gylburide (Glucovance)

Types of Oral Antidiabetic Agents:

Types of Oral Antidiabetic Agents Alpha-Glucosidase Inhibitors(delay absorption of glucose into circulation) Precose Non-Sulfonylurea Insulin Secretagogues (stimulate pancreas to secrete insulin) Prandin Thiazolidinediones or glitazones(stimulate insulin receptor sites to lower BS) Actos Avandia Dipeptidyl Peptidase-4 (DPP-4) inhibitor

Sites of Action of Oral Antidiabetic Agents:

Sites of Action of Oral Antidiabetic Agents

Insulin Therapy:

Insulin Therapy Blood glucose monitoring Categories of insulin (see Table 41-3 pg 1209) Rapid-acting Short-acting Intermediate-acting Very long-acting Inhaled insulin

Types of insulin:

Types of insulin Insulin type Onset PEAK Duration Rapid-Acting ( Novolog ) 5-15 min. 1 hour 2-4 hours Short-Acting (Regular) 30-60 min. 2-3 hours 4-6hours Intermediate (NPH, Lente ) 2-4 hours 4-12 hours 14-20hours Very Long Acting ( Lantus , Levemer ) 1 hour No peak 24hours *be sure the client is eating meals, typically (REGULAR) given 30minutes prior to eating meals *Rapid acting insulin is given when the meal is available to eat

Normal Pancreatic Insulin Release:

Normal Pancreatic Insulin Release

One Injection Per Day:

One Injection Per Day

Two Injections Per Day-Mixed :

Two Injections Per Day-Mixed

Three or Four Injections Per Day:

Three or Four Injections Per Day

Insulin Pump:

Insulin Pump

New Onset :

New Onset Test blood sugars before meals and 2 hours after meals Keep a log Possibly at 3am (long acting or bedtime insulin)

Sliding Scale/Correctional Coverage Insulin Coverage:

Sliding Scale/Correctional Coverage Insulin Coverage Sliding-scale coverage : Sometimes given to manage some inpatients' hyperglycemia. Patients receive insulin when glucose levels are high; the higher the glucose level, the more insulin is typical given. ( changes in insulin requirements when illness, stress, diet change, exercise) The scale is determined by the physician

Sliding Scale/Correctional Coverage Insulin Coverage:

Sliding Scale/Correctional Coverage Insulin Coverage Example: If Patients BG is 180mg/dL, This Patient would receive 2 units of regular insulin *hypoglycemia protocol may require the administration of glucose Blood Glucose mg/ dL Regular Insulin Coverage 0-60 or symptoms of hypoglycemia Do not give insulin, follow hypoglycemia protocol 151-199 give 2 units regular insulin 200-249 give 4 units regular insulin 250-299 give 8 units regular insulin >300 Call MD

Patient Teaching:

Patient Teaching

Teaching Patients to Manage their Diabetes (see teaching care plan):

Teaching Patients to Manage their Diabetes (see teaching care plan) Identify who you will teach (patient or sig. other) Sometimes the patient is unable to learn due to cognition issues, or grieving process from new diagnosis Assess readiness to learn Are they anxious or have misconceptions What is the current understanding of the Diagnosis Are there barriers to learning (language, reading ability (8 grade level), poor memory) Preferred method of learning

Teaching Patients:

Teaching Patients Organizing the information into brief, multiple sessions SEE article Diabetes Under Control Meter, Meds, Meals, Move and More, AJN July 2010 Vol. 110, no. 7

Teaching Patients Insulin Self-Management:

Teaching Patients Insulin Self-Management Use and action of insulin Symptoms of hypoglycemia and hyperglycemia Required actions Blood glucose monitoring Self-injection of insulin Sick-day “rules” (pg1226) Insulin pump use (if applicable)

A client with diabetes receives a combination of regular and NPH insulin at 0700 hours. The nurse teaches the client to be alert for signs of hypoglycemia at: :

A client with diabetes receives a combination of regular and NPH insulin at 0700 hours. The nurse teaches the client to be alert for signs of hypoglycemia at: 12pm to 1pm (1200-1300 hours) 11am and 5pm (1200 and 1700hours) 10am and 10pm (1000 and 2200hours) 8am and 11am (0800 and 1100 hours)

A client with diabetes receives a combination of regular and NPH insulin at 0700 hours. The nurse teaches the client to be alert for signs of hypoglycemia at: :

A client with diabetes receives a combination of regular and NPH insulin at 0700 hours. The nurse teaches the client to be alert for signs of hypoglycemia at: 12pm to 1pm (1200-1300 hours) 11am and 5pm (1200 and 1700hours) 10am and 10pm (1000 and 2200hours) 8am and 11am (0800 and 1100 hours) *Regular insulin peaks 2-3 hours and NPH peaks 4-12 hours .

Subcutaneous Injections: INSULIN :

Subcutaneous Injections: INSULIN Administration of INSULIN Rotating sites Rates of absorption Blood Glucose level Onset,peak,duration S/S hypoglycemia, hyperglycemia * Insulin is a naturally-occurring hormone secreted by the pancreas. Insulin is required by the cells of the body in order for them to remove and use glucose from the blood.

Subcutaneous Injections ::

Subcutaneous Injections : A subcutaneous injection is given in the fatty layer of tissue just under the skin.

Subcutaneous Injections: Insulin p554:

Subcutaneous Injections: Insulin p554 Rotating Sites : potential for insulin to cause hypertrophy is now a low risk and some clients may not rotate sites anymore. Rates of absorption: based on site 1 Abdomen………Fastest #2 Arms #3 Thighs 4 Buttocks……….Slowest

Mixing Insulin:

Mixing Insulin

Complications of insulin therapy:

Complications of insulin therapy

Hypoglycemia:

Hypoglycemia Abnormally low blood glucose level (below 50–60 mg/dL) Causes include too much insulin or oral hypoglycemic agents, too little food, and excessive physical activity

Hypoglycemia:

Hypoglycemia Manifestations Adrenergic symptoms : sweating, tremors, tachycardia, palpitations, nervousness, hunger Central nervous system symptoms: inability to concentrate, headache, confusion, memory lapses, slurred speech, numbness of lips and tongue, irrational or combative behavior, double vision, drowsiness * Severe hypoglycemia may cause disorientation, seizures, and loss of consciousness

PowerPoint Presentation:

Somogyi Effect Rebound hyperglycemia May be treated by decreasing the evening insulin dose Increasing the calories of bedtime snack.

PowerPoint Presentation:

Dawn Phenomenon A rising sugar in the early morning WITHOUT hypoglycemia during the night Treated by increasing insulin for overnight period Problematic in adolescence and young adult hood with peak growth hormone

Assessment HYPOGLYCEMIA:

Assessment HYPOGLYCEMIA Onset is abrupt and may be unexpected Symptoms vary from person to person Symptoms also vary related to the rapid decrease in blood glucose and usual blood glucose range Decreased adrenergic response may affect symptoms in persons who have had diabetes for many years probably related to autonomic neuropathy

Management of Hypoglycemia:

Management of Hypoglycemia Treatment must be immediate Give 15 g of fast-acting, concentrated carbohydrate 3 or 4 glucose tablets 4–6 ounces of juice (prefer apple) or regular soda (not diet soda) 6–10 hard candies 2–3 teaspoons of honey Retest blood glucose in 15 minutes, retreat if >70 mg/ dL or if symptoms persist more than 10–15 minutes and testing is not possible. Provide a snack with protein and carbohydrate unless the patient plans to eat a meal within 30–60 minutes.

Emergency Measures:

Emergency Measures If the patient cannot swallow or is unconscious: Subcutaneous or intramuscular glucagon 1 mg 25–50 mL 50% dextrose solution IV

A client newly diagnosed with diabetes mellitus has been stabilized with daily insulin injections. A nurse prepares a discharge teaching plan regarding the insulin and plans to reinforce which of the following?:

A client newly diagnosed with diabetes mellitus has been stabilized with daily insulin injections. A nurse prepares a discharge teaching plan regarding the insulin and plans to reinforce which of the following? Always keep insulin vials in the refrigerator Ketones in the urine signify a need for less insulin Increased amounts of insulin before unusual exercise Systematically rotate insulin within one anatomic site

A client newly diagnosed with diabetes mellitus has been stabilized with daily insulin injections. A nurse prepares a discharge teaching plan regarding the insulin and plans to reinforce which of the following?:

A client newly diagnosed with diabetes mellitus has been stabilized with daily insulin injections. A nurse prepares a discharge teaching plan regarding the insulin and plans to reinforce which of the following? Always keep insulin vials in the refrigerator Ketones in the urine signify a need for less insulin Increased amounts of insulin before unusual exercise Systematically rotate insulin within one anatomic site

Acute Complications of Diabetes:

Acute Complications of Diabetes Diabetic ketoacidosis (DKA) Hyperglycemic hyperosmolar nonketotic syndrome (HHNS) aka hyperosmolar nonketotic coma or hyperglycemia hyperosmolar syndrome (HHS)

Diabetic Ketoacidosis (DKA):

Diabetic Ketoacidosis (DKA)

Diabetic Ketoacidosis (DKA):

Diabetic Ketoacidosis (DKA) Caused by an absence of or inadequate amount of insulin resulting in abnormal metabolism of carbohydrate, protein, and fat Clinical features Hyperglycemia Dehydration Acidosis

Diabetic Ketoacidosis (DKA):

Diabetic Ketoacidosis (DKA) Manifestations include polyuria, polydipsia, blurred vision, weakness, headache, anorexia, abdominal pain, nausea vomiting, acetone breath , hyperventilation with Kussmaul respirations (deep and rapid) , and mental status changes

Pathophysiology of DKA:

Pathophysiology of DKA Refer to fig. 41-7 (1225) http://www.youtube.com/watch?v=m0sIW_JTecA

Assessment of DKA:

Assessment of DKA Blood glucose levels vary from 300–800 mg/ dL *Severity of DKA is not related to blood glucose level Ketoacidosis is reflected in low serum bicarbonate (<15mEq/L) and low pH(6.8-7.3) ; low PCO 2 reflects respiratory compensation Ketone bodies in blood and urine Electrolytes vary according to water loss and level of hydration (k low, high or normal)

Prevention/causes:

Prevention/causes Decreased or missed dose of insulin (insulin mismanagement/error) Illness/infection (follow the sick day rules) Undiagnosed Diabetes

Treatment of DKA:

Treatment of DKA Rehydration with IV fluid IV continuous infusion of regular insulin Reverse acidosis and restore electrolyte balance Note: rehydration leads to increased plasma volume and decreased K + , insulin enhances the movement of K + from extracellular fluid into the cells Monitor Blood glucose and renal function/UO EKG and electrolyte levels— Potassium VS, lung assessments, signs of fluid overload

Hyperglycemic Hyperosmolar Nonketotic Syndrome:

Hyperglycemic Hyperosmolar Nonketotic Syndrome Hyperosmolality and hyperglycemia occur due to lack of effective insulin. Ketosis is minimal or absent. Hyperglycemia causes osmotic diuresis with loss of water and electrolytes; hypernatremia, and increased osmolality occur.

Hyperglycemic Hyperosmolar Nonketotic Syndrome:

Hyperglycemic Hyperosmolar Nonketotic Syndrome Manifestations include hypotension, profound dehydration, tachycardia, and variable neurologic signs due to cerebral dehydration. BS > 600mg/dL High mortality (due to the delay in seeking treatment)

Treatment of HHNS:

Treatment of HHNS Rehydration Insulin administration Monitor fluid volume and electrolyte status Prevention Blood Glucose Self Monitoring Diagnosis and management of diabetes Assess and promote self-care management skills

PowerPoint Presentation:

A client is brought to the ED in an unresponsive state, and a diagnosis of hyperglycemic hyperosmolar nonketotic syndrome is made. The nurse would immediately prepare to initiate which of the following anticipated physician's orders? Endotracheal intubation 100units of NPH insulin Intravenous infusion of NS Intravenous infusion of sodium bicarbonate

PowerPoint Presentation:

A client is brought to the ED in an unresponsivestate , and a diagnosis of hyperglycemic hyperosmolar nonketotic syndrome is made. The nurse would immediately prepare to initiate which of the following anticipated physican’s orders? Endotracheal intubation 100units of NPH insulin Intravenous infusion of NS Intravenoud infusion of sodium bicardonate

PowerPoint Presentation:

A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in an emergency room. Which finding would a nurse expect to note as confirming this diagnosis? Comatose state Decreased Urine output Increased respirations and increased pH Elevated blood glucose level and low plasma bicarbonate level

PowerPoint Presentation:

A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in an emergency room. Which finding would a nurse expect to note as confirming this diagnosis? Comatose state Decreased Urine output Increased respirations and increased pH Elevated blood glucose level and low plasma bicarbonate level

PowerPoint Presentation:

A nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis . The client demonstrates an understanding of the teaching by stating that glucose will be taken if which of the following symptoms develops? Polyuria Shakiness Blurred vision Fruity breath odor

PowerPoint Presentation:

A nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis . The client demonstrates an understanding of the teaching by stating that glucose will be taken if which of the following symptoms develops? Polyuria Shakiness Blurred vision Fruity breath odor

Long-term Complications :

Long-term Complications

Long-Term Complications of Diabetes:

Long-Term Complications of Diabetes Macrovascular complications Accelerated atherosclerotic changes Coronary artery disease, cerebrovascular disease, and peripheral vascular disease Microvascular complications Diabetic retinopathy, nephropathy Neuropathic changes Peripheral neuropathy, autonomic neuropathies, hypoglycemic unawareness, neuropathy, sexual dysfunction

Diabetic Retinopathy Refer to fig. 41-8 pg1232 :

Diabetic Retinopathy Refer to fig. 41-8 pg1232 Leading cause of blindness among people between 20-74years old Microaneurysms , intraretinal hemorrhage, hard exudates, focal capillary closure Assessment with ophthalmoscope Prevention by controlling blood sugar and hypertension Referral for services for the blind including learning Braille and guide dogs Assess and maintain independence

Through ophthalmoscope:

Through ophthalmoscope

PowerPoint Presentation:

Microaneurysms

Neuropathies-Autonomic Nervous System:

Neuropathies-Autonomic Nervous System Hypoglycemic unawareness Sudomotor Neuropathy (decrease sweating of extremities yields increased risk for foot ulcers) Sexual Dysfunciton Vaginal dryness/vaginitis Erectile dysfunction

Nephropathy:

Nephropathy Renal disease secondary to diabetic microvasular changes in the kidney Type I show signs 10-15 years 50% of new cases of end-stage renal disease 25% require dialysis or transplant

Nephropathy:

Nephropathy Blood glucose levels are elevated consistently, kidney’s filtration mechanism is stressed allowing blood proteins to leak into the urine increased pressure causing nephropathy

Nephropathy:

Nephropathy Manifestations Breakdown of insulin decreases Frequent hypoglycemia episodes Multi-system failure Vision, ulcers, heart failure, nocturnal diarrhea

Nephropathy: Assessment:

Nephropathy: Assessment Check urine annually for microalbuminuria >30mg/24 hours on 2 consecutive random tests is positive CR and BUN Development of hypertension

Development of hypertension:

Development of hypertension The kidney is a filtering organ that retains vital blood components and excretes excess fluid. If too much fluid is retained, BP rises. If too little fluid is retained, BP decreases. Arterial pressure within the renal artery triggers a feedback loop. The kidneys excrete sodium, which osmotically draws fluid into the excretory system in a process called pressure diuresis . This causes a decrease in blood fluid volume and arterial pressure. As pressure within the renal artery decreases, the kidneys reflexively secrete an enzyme called renin . This enzyme causes the formation of a protein called Angiotensin I. Angiotensin I directly stimulates the kidneys to retain sodium and fluid. Angiotensin I is converted in the lungs, via the enzyme angiotensin converting enzyme (ACE) to Angiotensin II. Angiotensin II is a potent vasoconstrictor which increases total peripheral vascular resistance and hence elevates BP.

Management of Nephropathy:

Management of Nephropathy Control hypertension ACE inhibitors may delay onset of proteinuria of if + for microalbuminuria AR( angiotension receptor blocking agents Prevent UTI Avoid nephrotoxic substances (iv dye, antibiotics etc) Adjust medications based on renal ability Low sodium/low protein diet

Management of Nephropathy:

Management of Nephropathy Treatment for end stage renal failure Hemodialysis Peritoneal dialysis http://www.davita.com/treatment-options/home-peritoneal-dialysis/videos Transplant (75-80% chance it will function for 5 years)

Neuropathic Ulcers:

Neuropathic Ulcers

Foot and leg problems:

Foot and leg problems Sensory neuropathy Pain is undetected Infection Motor neuropathy (deformity) Pressure points Peripheral Vascular Disease Poor perfusion Poor healing Immunocompromise Impairs ability for leukocytes to destroy bacteria Lowered resistance to infection

Teach proper foot care:

Teach proper foot care Page 1237 Review from peripheral vascular lecture ASN 202

Teaching Patients Self-Care:

Teaching Patients Self-Care Assess knowledge and adherence to plan of care. Provide basic information about diabetes, its cause and symptoms, and acute and chronic complications and their treatment. Teach self-care activities to prevent long-term complications including foot care, eye care, and risk-factor management. Include family in plan of care. Provide information, encourage health promotion activities, and recommended health screenings.

Promoting Hygiene: foot care:

Promoting Hygiene: foot care Wash and Dry Feet Daily Use mild soaps. Use warm water. Pat skin dry; do not rub. Thoroughly dry feet. After washing, use lotion on feet to prevent cracking. Do not put lotion between toes.

Promoting Hygiene: foot care:

Promoting Hygiene: foot care Care of Toenails Cut toenails after bathing, when they are soft. Cut toenails straight across and smooth with a nail file. Avoid cutting into the corners of toes. Diabetic Client may need an order for a podiatrist to cut toenails.

Promoting Hygiene: foot care Care for Clients with Diabetes:

Promoting Hygiene: foot care Care for Clients with Diabetes Diabetes is a chronic (long-term) illness that occurs when your body does not make enough insulin. Insulin is a hormone that allows your cells to use the sugar in your blood for energy. Chronic high blood sugar levels can damage the blood vessels and nerves in your legs and feet.

Factors affecting foot care of a Diabetic Client:

Factors affecting foot care of a Diabetic Client Neuropathy: Neuropathy is nerve damage. Nerves carry information needed for you to feel touch, pressure, pain, and temperature. Peripheral vascular disease (PVD) occurs when your blood vessels become narrow or blocked. PVD causes decreased blood flow to your feet. Blood contains oxygen and cells that are needed for your body to heal when it is injured. You may heal slowly and you may have an increased risk of infection Poor vision: Problems with your vision may make it hard for you to see problems with your feet.

Foot Care of a Diabetic Client:

Foot Care of a Diabetic Client Assess for ability to feel sensation in feet (pain, temperature, pressure) Assess capillary refill, color and temperature of feet Palpate the pedal pulses and compare bilaterally Inspect for lesions, callus, corns, ingrown toe nails fungal infections Foot care can be delegated EXCEPT for patients with diabetes or circulatory compromise.

PowerPoint Presentation:

A nurse is preparing a teaching plan for a client with diabetes mellitus regarding proper foot care. Which instruction is included in the plan? 1. soak feet in hot water 2. avoid using a mild soap on the feet 3. apply a moisturizing lotion to dry feet but not between the toes 4. always have a podiatrist cut your toe nails; never cut them yourself

PowerPoint Presentation:

A nurse is preparing a teaching plan for a client with diabetes mellitus regarding proper foot care. Which instruction is included in the plan? 1. soak feet in hot water 2. avoid using a mild soap on the feet 3. apply a moisturizing lotion to dry feet but not between the toes 4. always have a podiatrist cut your toenails;never cut them yourself The client is instructed to use a moisturizing lotion on the feet and to avoid applying the lotion between the toes. The client should be instructed not to soak the feet and should avoid hot water to prevent burns. The client may cut the toenails straight across and even with the toe itself and would consult a podiatrist if the toenails were thick or hard to cut or if vision were poor. The client should be instructed to wash the feet daily with a mild soap.

Insulin and the hospitalized patient:

During periods of stress such as surgery, blood glucose increases due to stress hormones Epinephrine Norepi Glucagon Cortisol Growth hormone. Insulin and the hospitalized patient

Hyperglycemia During Hospitalization:

Hyperglycemia During Hospitalization Changes in usually regime (more food, less insulin, less activity) Medication changes (corticosteroids) IV dextrose without adequate insulin Over vigorus treatment of hypoglycemia Inappropriate withholding of insulin or inappropriate use of sliding scales Mismatched timing of insulin and meal delivery

Hypoglycemia during hospitalization:

Hypoglycemia during hospitalization Overuse of sliding scale insulin Lack of change in insulin when diet changes Over treatment of hyperglycemia Insulin given too frequent before peak time is reached leading to cumulative effect Delayed meal administration of lispro, aspart or apidra insulin (eat with in 5 minutes) Arragen for a snack if the meal is delayed

Diabetes: NPO:

Diabetes: NPO Eliminate rapid acting insulin dose in the morning Give ½ dose of the intermediate or long acting insulin In type I diabetes Sugar may still rise due to liver release of glucose Elimination of insulin can lead to DKA In type II diabetes Usually don’t develop DKA, but should have glucose checked frequently (4-6 hours) Intermediate insulin given every 12 hours. IV dextrose to prevent ketosis

Diabetes: Clear Liquid Diet:

Diabetes: Clear Liquid Diet Should be full sugar foods not reduce or diet Glucose checks and Insulin should be timed with meals

Diabetes:Enteral Feedings:

Diabetes:Enteral Feedings Tube feedings formula high in simple carbs and less protein and fat Results in blood sugars Continuous TF require insulin administered at regular intervals

Diabetes: Parenteral Nutrition:

Diabetes: Parenteral Nutrition Similar to enteral feedings

PowerPoint Presentation:

A nurse needs to maintain food and fluid intake to minimize the risk of dehydration in a client with diabetes mellitus who has gastroenteritis. The appropriate nursing intervention is to: Offer water only until the client is able to tolerate solid foods Withhold all fluids until vomiting has ceased for at least 4 hours Encourage the client to take 8-12 oz of fluid every hour while awake Maintain clear liquid diet for at least 5 days before advancing to solids to allow inflammation of the stomach and bowel to dissipate

PowerPoint Presentation:

A nurse needs to maintain food and fluid intake to minimize the risk of dehydration in a client with diabetes mellitus who has gastroenteritis. The appropriate nursing intervention is to: Offer water only until the client is able to tolerate solid foods Withhold all fluids until vomiting has ceased for at least 4 hours Encourage the client to take 8-12 oz of fluid every hour while awake Maintain clear liquid diet for at least 5 days before advancing to solids to allow inflammation of the stomach and bowel to dissipate (too long)

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